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Keeping our NHS fit for public’s purpose

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by Oliver Evans, Health reporter, also covering Kidlington. Call me on 01865 425271

WITH financial problems, leadership changes and mounting demand on services, Oxfordshire Clinical Commissioning Group (OCCG) has had a tumultuous first year.

Ian Wilson was brought in as interim chief executive last December after previous holder Dr Stephen Richards stepped down – owing to the demands of the job – to take up a new role as clinical chairman.

The OCCG’s home in an anonymous-looking office building at Oxford Business Park South, Cowley, belies its importance – it decides where most NHS spending, from hospitals to ambulances, some £630m this year, goes.

This division between providers of services like Oxford University Hospitals NHS Trust and OCCG as “commissioners” was introduced by former Tory PM Margaret Thatcher to drive competition, albeit within an NHS “internal market”.

Off the bat, Mr Wilson,

Mr Ian Wilson

says it has been a “rollercoaster” year with the OCCG forecasting a £6.1m deficit this year and £6.9m next year, despite the demand that all NHS authorities end in surplus.

He said: “The main challenges have been with regards to the financing of the whole health and social care economy and the lack of financial balance, the mismatch between the amount of money that is available to buy the necessary health services and the spend that was going out on them.”

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But he said: “I don’t think it’s fair to judge the performance of CCGs nationally on whether this experiment has been a success by the 20 or 25 CCGs that are in difficulty than the 100 which aren’t.”

The former director of social services at Tower Hamlets Council, Mr Wilson retired in 2007 and has worked as a “turnaround” specialist in struggling trusts, five so far in the NHS. A new chief executive’s appointment is imminent.

A key problem has been the heavy demand on the acute hospital trust – which has seen A&E waiting time targets missed and high levels of bed-blocking – and the resulting higher-than-expected bills for the OCCG.

The NHS has long said it wants simple, low-risk care provided in the community like GP surgeries than in more expensive hospitals.

But Mr Wilson said: “It must be the case that all the partners in this have, over some period of time, despite best efforts on all their parts, failed to get the balance right between what goes on in the acute trust and what goes on everywhere else.”

Nationally set fees will give the OCCG no choice but to cut hospital funding, with provisional figures showing a drop of six per cent from £345m this year to £324.8m in 2018/19 but with a 199 per cent rise in home care from £33.7m to £100.6m to make up the difference.

But Mr Wilson said he has been determined not to “turn around the financial position without knee-jerk, draconian cuts, salami slicing” of services as this could do more long-term damage than good.

In January Dr Richards lost a GP election to remain clinical chairman to city GP Dr Joe McManners and Mr Wilson said: “I think it has been unsettling for the staff group as has the almost continuous criticism of the CCG with regard to its budget and finances and other things. I think the staff group have done really well to keep going.”

He added: “Some GPs are very involved in working their socks off on the new CCG but it is not the majority of GPs, the majority of them have more than enough work because of the very great increase in GP case loads.”

He added of future challenges: “It is often the case that organisations that have been in a bit of trouble can get to the position where people are so worried about their reputations as organisations that they put a silo around themselves in order to not suffer reputational damage. That gets in the way of whole system working.”

TAKING the pressure off major hospitals like Oxford’s John Radcliffe is a key priority for the OCCG and its funding of a unit at Witney Community Hospital is part of these efforts.

An emergency multi-disciplinary unit (EMU) opened in October after a successful 2010 pilot at Abingdon Community Hospital aimed at tackling the county’s chronic “bed blocking” problem, also called delayed discharges.

This is when a patient - usually an OAP – is well enough to leave major hospitals but cannot because other services are not available in the community.

The EMU designs as a half-way house by treating serious conditions, except for heart attacks and strokes.

Dr Miles Carter, West Oxfordshire locality clinical director for the OCCG, said: “I’m very pleased that this emergency multi-disciplinary unit is up and running, and I’m sure it will provide an effective health care service for the people of West Oxfordshire and beyond.

“People who can be treated in this way are much more likely to recover quickly and to maintain the level of independence they enjoyed before their acute illness.”

‘Very difficult hand’

Andrew Smith MP

“The clinical commissioning group was dealt a very difficult hand by the Government’s costly re-organisation of the NHS, says Oxford East Labour MP Andrew Smith “It is clear that the challenge in leading local health provision to get the best outcomes and treatment for patients was even more demanding than the CCG realised.

“Given the enormous pressures facing local hospitals and other health services and the relatively low funding per resident in Oxfordshire, there is going to need to be close and careful working between all agencies to tackle the challenges of waiting times, the pressure at A&E, and bed-blocking. We have some wonderful health care locally, with dedicated and valued staff, but much of the system is not far from breaking point.”

‘Looking forward to working with team’

Ed Vaizey MP

WANTAGE Conservative MP Ed Vaizey, says: “Oxfordshire Clinical Commissioning Group has had a tough first year, and has faced significant challenges.

“I am pleased that the new leaders at the CCG have acknowledged the scale of what needs doing, and are working on the best ways to tackle the task.

“I am looking forward to working with the new team to ensure that my constituents continue to receive the best possible health care from our excellent local health providers.”

‘A very good start’

Sir Tony Baldry MP

“I think that the clinical commissioning group has made a very good start, says Banbury Conservative MP Sir Tony Baldry.

“Ian Wilson and his team have a good grip on what needs to be done.

“It is however always going to be challenging for the NHS in Oxfordshire given that the Oxfordshire CCG have the lowest funding per head of any CCG in the country.

“I think it is a matter of genuine concern that the Labour Party so strongly objected to the recommendations of a wholly independent panel that NHS England bottled it and did not reform the formula in accordance with the recommendations of the panel which would have significantly improved the financial situation of the NHS in Oxfordshire by more fairly reflecting the demographic structure.”

‘Politicians want everything’

Dr Prit Buttar

“We simply don’t have enough money to do everything that we want to do,” says Dr Prit Buttar, chairman of the Oxfordshire Local Medical Committee of the British Medical Association.

“There are three variables: convenience or speed, quality and cost. The problem is that you can control only two – the third has to be free to float in order to accommodate your choices with the other two. So, if you want a convenient, high-quality service, the cost will be very high. If you fix costs, as the NHS does, then you will have to compromise convenience or quality, or a bit of both.

“The problem is that politicians want everything – convenience, quality and a fixed cost, and that is simply impossible.

“We have pressures from an ageing population and more expensive treatments, and frankly absurd expectations in terms of convenience and accessibility. It should also be remembered that improved survival in conditions like heart disease, stroke, cancer and so on comes with a price – these patients require additional resources, and therefore funding, to continue their lives. There comes a stage where regardless of how efficient you are, you simply cannot contain those pressures, and something has to give way. My own belief is that Oxfordshire has reached that stage, but the rest of the country will reach the same crisis sooner or later, which is why other areas are watching Oxfordshire.”

Healthwatch welcome the greater openness

Mr Larry Sanders

Larry Sanders, chairman of Oxfordshire Healthwatch, the county’s official health and social care watchdog, pictured, says: “Healthwatch Oxfordshire welcomes the greater openness which has been shown by OCCG Leaders Ian Wilson and Joe McManners.

“We welcome some evidence that figures on the number of people affected by delayed discharges have begun to improve although Oxfordshire is still bottom of the country and that is a major cause for concern. Expenditure on mental health services is forecast to fall substantially over the forthcoming years of the group’s plans and this gives cause for concern in respect of how OCCG will achieve their commitment to health equality in the light of this reduced level of funding.”

June: Dr Richards says bed-blocking – where patients are stuck in a hospital bed despite being well enough to go home – is still too high, two years after vowing to tackle the issue.

September: NHS England announces £10m to tackle an expected rise in demand over the winter, as OCCG medical director says of bed-blocking: “We are all hanging our heads in shame.” Later that month we report it could hit an £11m overspend by March 31.

October: Dr Richards announces he is splitting his role, saying the OCCG “needs a stronger clinical voice than I was able to give it”.

November: Six public meetings are announced for November and December to get views on the OCCG’s five-year plan, with another held in Oxford in January. More than 350 attend.

December: Management consultants Deloitte have been brought in at a cost of £350,000 for three months to help find savings, we report.

Later that month we report it will get an extra £4.7m on top of its £650m budget for 2014/15.

January: Ian Wilson tells the final public meeting at Oxford Town Hall he cannot guarantee services won’t deteriorate under savings.

We later report patients could be denied a bed at a community hospital closest to their home as part of efforts to tackle bed-blocking.

March: plans to let private firms run part of maternity, OAP and mental health services are scaled down.

Bosses agree to still move forward with plans to buy services based on patient outcomes rather than number treated, but with state providers.